Kentucky Medicaid identifies independent lab services as Provider Type (37). To enroll or bill Kentucky Medicaid, independent laboratory providers must be:
- Enrolled with Medicare
- Licensed in the state in which it is located. In Kentucky, independent lab service providers must contact the Office of Inspector General, Division of Health Care for a survey/license
Clinical Laboratory Improvement Amendments (CLIA) certificate certified by the Centers for Medicare and Medicaid Services
- Enrolled with Kentucky Medicaid, and if applicable, enrolled with the managed care organization (MCO) of any beneficiary for whom it provides services
- Headed by a laboratory director with education and experience based on CLIA level of certification
A laboratory provider may perform Medicaid laboratory services for the Medicaid beneficiary only to the extent authorized by the provider's CLIA certificate. Services are prescribed by a physician, physician assistant, podiatrist, dentist, oral surgeon, advanced registered nurse practitioner or optometrist.
Independent labs must meet the coverage provisions and requirements of 907 KAR 1:028 to provide covered services. Any services performed must fall within the scope of practice for any provider. Listing of services in an administrative regulation is not a guarantee of payment. Providers must follow all relevant Kentucky Medicaid regulations. All services must be medically necessary.
Reimbursement rates for independent labs are listed on the Kentucky Medicaid lab fee schedule updated annually by CMS and 907 KAR 1:028. Services covered by Kentucky Medicaid are listed on the Kentucky Medicaid Independent Lab Fee Schedule. Others are approved on a case-by-case basis by Kentucky Medicaid or exceptions approved by the medical director.
Duplication of Service
Kentucky Medicaid will not reimburse for a service provided to a beneficiary by more than one provider of any program in which the service is covered during the same time period.
CareWise provides prior authorizations for any fee-for-service (FFS) beneficiary. Each MCO provides prior authorizations for its beneficiaries.
Kentucky Medicaid currently contracts with Gainwell Technologies to process Kentucky Medicaid FFS claims. Each MCO processes its own claims.
Kentucky Medicaid uses the National Correct Coding Initiative edits as well as the McKesson Claim Check System to verify codes that are mutually exclusive or incidental. Kentucky Medicaid also uses Correct Procedural Terminology (CPT) codes and Healthcare Common Procedure Coding system codes. Kentucky Medicaid requires the use of ICD-10 codes on all claims submitted for reimbursement. KY Medicaid requires the use of CMS 1500 billing forms. Providers must bill Kentucky Medicaid using the correct CPT codes.
Appeal of denied FFS claims must be submitted to Gainwell Technologies. The request must include the reason for the request along with a hard copy claim. Please refer to the MCO in question when appealing a claim.
Claims must be received within 12 months of the date of service or six months from the Medicare pay date, whichever is longer, or within 12 months of the last Kentucky Medicaid denial. Please refer to the MCO in question when appealing a claim.
Provider Contact Information
If you can't find the information you need or have additional questions, please direct your inquiries to:
FFS Billing Questions - Gainwell Technologies - (800) 807-1232
Provider Questions - (855) 824-5615
Provider Enrollment or Recertification - (877) 838-5085
KyHealth.net assistance -
Gainwell Technologies- (800) 205-4696
Pharmacy Questions - (800) 432-7005
Pharmacy Clinical Support Questions - (800) 477-3071
Pharmacy Prior Authorization - (800) 477-3071
Physician Administered Drug (PAD) List - Pharmacy Branch - (502) 564-6890
CLIA Inquiries/Kentucky Office of Inspector General (OIG) – (502) 564-7963
CLIA (CMS Regional Office in Atlanta) – (404) 562-7451
Provider MCO Information
Aetna Better Health of Kentucky - (855) 300-5528
Anthem Blue Cross Blue Shield - (855) 690-7784
Humana Healthy Horizons in Kentucky- (800) 444-9137
Passport Health Plan by Molina Healthcare - (844) 778-2700
UnitedHealthcare Community Plan - (866) 293-1796
WellCare of Kentucky - (877) 389-9457